Humanpapilloma virus (HPV) is now the leading cause of certain types of throat cancer. Dr. Michael Moore, director of head and neck surgery at UC Davis and an HPV-related cancer expert, answers some tough questions about the trend and what can be done about it.

Q: What is HPV and how is it related to head and neck cancers?

A: There are about 150 different types of HPV, but HPV 16 is the one that most frequently causes cancers that affect the tissue in the oropharynx, which includes back of the throat, soft palate, tonsils and the back or base of the tongue. You can get non-cancerous lesions from other types of HPV that look like warts in the nose, mouth or throat, called papillomas. Some can develop in childhood just from exposure early in life. Some develop later in life and only occasionally turn into cancer.

Q: How do you get HPV?

A: HPV can spread from mother to her baby around the time of delivery. It also spreads through unprotected vaginal, anal or oral sex, and even open-mouth kissing. Some people have been found to be infected without an obvious cause.

Q: How does HPV cause cancer?

A: Most people who are infected clear the virus on their own. In a small group of people it hangs around and causes a persistent infection. Around 1% of US adults have a persistent HPV 16 infection, and in a small subset of these individuals the DNA of the virus incorporates itself into the DNA of the person infected and can start to make proteins that then predispose that person to developing cancer.

Q: How prevalent are HPV-related throat cancers?

A: Traditionally, the risk factors for head and neck cancers were tobacco and alcohol use, but over the last 20 or 30 years we found the rates of those cancers going down because smoking rates have gone down. Meanwhile, the incidence of head and neck cancers related to HPV has gone up more than 200 percent over this time period. This increase has been so dramatic that HPV-related throat cancer has recently surpassed cervical cancer as the most common HPV-related cancer in the United States.

Q: Why are the rates going up?

A: Unlike with cervical cancer, in which the PAP smear is highly effective at finding potentially cancerous or pre-cancerous cells, there is no good screening test for these head and neck cancers. Currently, the use of swab tests for HPV is effective in finding out if you have an HPV infection, but not in determining if the infection will be persistent or if you will ever develop cancer. As a result, such tests are not endorsed as a way to screen for these tumors.

Q: Do both men and women get thee cancers?

A: Men are four times more likely to be diagnosed with an HPV-related head and neck cancer. Researchers don’t yet know why. It may have to do with sexual practices or related to the types of exposure they receive. The local or systemic immune system may also play a role.

Q: Can HPV-related head and neck cancers be prevented?

A: We have a very effective vaccine against HPV, and we know the vaccine can prevent oral HPV infections. In fact, studies have shown that the vaccine is 93 percent effective in preventing the oral infections that cause head and neck cancers. We recommend two injections for adolescents under age 15 and three for those over 15. The vaccine is recommended for children age 10-11, but vaccination can start in children as young as age 9, and in boys as late as age 21 and in girls as late as 26. It is also important to maintain safe sexual practices and avoid other potentially cancer-causing exposures such as tobacco, alcohol and marijuana.

Q: What are the main barriers to vaccination?

A: Studies have shown that the biggest reason kids don’t get it is lack of physician endorsement or recommendation. The American Cancer Society is trying to change that, asking physicians to introduce it to parents when they discuss other adolescent vaccines. There has also been concern that parents aren’t comfortable talking about sexuality with their children, and some have worried that if the child gets the vaccine they are more likely to be sexually active. That theory has been debunked in scientific studies.

Q: How safe and effective is the HPV vaccine?

A: It has a very safe track record and is continually undergoing evaluation to look for potential side effects. While there are some risks with any vaccine, one of the most common side effects is that patients may feel light headed after being vaccinated, and it is recommended they are observed for 15 minutes afterward.

Beating cancer is a race against time. Developing radiation therapy plans — individualized maps that help doctors determine where to blast tumours — can take days. Now, Aaron Babier (MIE PhD candidate) has developed automation software that aims to cut the time down to mere hours.

Their software uses artificial intelligence (AI) to mine historical radiation therapy data. This information is then applied to an optimization engine to develop treatment plans. The researchers applied this software tool in their study of 217 patients with throat cancer, who also received treatments developed using conventional methods.

The therapies generated by Babier’s AI achieved comparable results to patients’ conventionally planned treatments. — and it did so within 20 minutes. The researchers recently published their findings in Medical Physics.

“There have been other AI optimization engines that have been developed. The idea behind ours is that it more closely mimics the current clinical best practice,” says Babier.

If AI can relieve clinicians of the optimization challenge of developing treatments, more resources are available to improve patient care and outcomes in other ways. Health-care professionals can divert their energy to increasing patient comfort and easing distress.

“Right now treatment planners have this big time sink. If we can intelligently burn this time sink, they’ll be able to focus on other aspects of treatment. The idea of having automation and streamlining jobs will help make health-care costs more efficient. I think it’ll really help to ensure high-quality care,” says Babier.

Babier and his team believe that with further development and validation, health-care professionals can someday use the tool in the clinic. They maintain, however, that while the AI may give treatment planners a brilliant head start in helping patients, it doesn’t make the trained human mind obsolete. Once the software has created a treatment plan, it would still be reviewed and further customized by a radiation physicist, which could take up to a few hours.

“It is very much like automating the design process of a custom-made suit,” explains Chan. “The tailor must first construct the suit based on the customer’s measurements, then alter the suit here and there to achieve the best fit. Our tool goes through a similar process to construct the most effective radiation plan for each patient.”

Trained doctors, and often specialists, are still necessary to fine-tune treatments at a more granular level and to perform quality checks. These roles still lie firmly outside the domain of machines.

For Babier, his research on cancer treatment isn’t just an optimization challenge.

“When I was 12 years old, my stepmom passed away from a brain tumour,” Babier shares.

“I think it’s something that’s always been at the back of my head. I know what I want to do, and that’s to improve cancer treatment. I have a family connection to it. It adds a human element to the research,” says Babier.

As if you don’t have enough reasons to feel guilty for avoiding the dentist, it turns out a healthy mouth is linked to a lot more. than the absence of cavities and plaque. Researchers say our mouths are home to an ecosystem of billions of bacteria with influence far beyond our teeth and gums—influence they are just starting to unravel.

“We know that oral bacteria affect almost every aspect of our health—metabolism, cardiovascular system, neurological health, and more,” says Yiping Han, a microbiologist at Columbia University Dental and Medical Schools in New York City.

Scientists like Han are grappling with questions that will change our understanding of how the body works. Not only are they studying the ways bacteria in our mouths interact with one another but they’re also investigating why mouth bacteria show up in other parts of the body, such as the lining of the heart, around tumors, and even in the brain.

The idea that our bodies host a world of bacteria may sound familiar. For the past decade, we’ve seen a surge of scientific research on the gut microbiome, which describes the bacteria that live in the gastrointestinal tract. Gut bacteria seem to have a hand in a surprising number of functions, from the predictable (like digestion and nutrient uptake) to the more surprising (obesity and depression). So it makes sense that the next place for a breakthrough would be upstream—the mouth.

Scientists have identified 700-plus strains of bacteria swiped from cheeks around the world, which makes the mouth the second-largest microbiome in the body (just behind the GI tract). And they’re trying to figure out the roles of these strains. Sussing out what combination of bacteria makes a person healthy or sick would be a major step in staving off diseases.

For instance, certain bacteria are the culprits behind a bunch of maladies that send you to the dentist, like plaque, gum disease, and bad breath. Those kinds of discoveries get dentists excited. That said, what’s really interesting is that oral bacteria pop up all over the body and are linked to a host of other medical issues.

This newfound knowledge is made possible by advancements in DNA and RNA decoding, and microscopic imaging. Scientists upload new information to oral microbiome repositories at the Forsyth Institute in Cambridge, Massachusetts; Ohio State University; and Los Alamos National Laboratory in New Mexico.

This knowledge sharing has helped to unravel some long-standing medical mysteries. For instance, doctors have, for decades, puzzled over why people with cardiovascular issues, like endocarditis (an infection of the lining of the heart) or clogged arteries, also have gum disease. Turns out that the inflamed gums allow oral bacteria to get into the bloodstream, where they can wreak havoc on the heart and vessels.

That’s not the only way that bacteria in the mouth end up elsewhere. Swallowing a teaspoon of saliva disperses 5 million bacteria into your digestive tract, says Colleen Cavanaugh, a biology researcher at Harvard University. (Preliminary findings suggest that oral sex can be a conduit, too, Han says.)

“It’s a mobile microbiome,” Han says. “There are some bacteria that, when they’re in the mouth, they’re mostly harmless, but when they go to other sites in the body, they become pathogens,” Han says.

Take Fusobacterium nucleatum, or Fn for short. In your mouth, it causes dental plaque. But it’s a menace if it encounters a colon cancer tumor. Han’s lab has found that Fn acts as an accelerant, prompting a tumor to grow faster, protecting it from chemotherapy drugs, and encouraging it to metastasize to the liver (which is particularly dangerous). Fn has also been found in the joint fluid in people with rheumatoid arthritis, an inflammatory disease. And it’s even been detected in brain abscesses, meaning it has the ability to jump the blood-brain barrier, which is quite a feat— very few substances that float in the blood can get to the brain and spinal cord.

Does Fn cause colon cancer? No. But down the road, knowing that a patient’s tumor is being bodyguarded by Fn may change the way he’s cared for.

And new research suggests that the oral bacteria can also have a direct impact on how cancer plays out. A study published in Scientific Reports found that people who are diagnosed with oral or throat cancers—which are notoriously difficult to treat and have high rates of mortality—had similar oral microbiome compositions.

There are a couple of explanations for why people with the same disease would share similar bacteria. It could be that bad habits like drinking, smoking, and poor oral hygiene create the perfect conditions for certain bacteria to grow (and others to die off). Genetics probably play a role, in that a person’s mouth is predisposed to having more of some bacteria, less of others. Most likely, it’s a little bit of both. Regardless, knowing how the microbiome changes composition when it’s sick may help doctors prevent and treat disease.

Scientists are interested not only in the bacteria they find but also in what they don’t. A six-year study from the University of Copenhagen finds that not enough of bacteria called Lactobacillus can be a predictor of weight gain. We’re not at the place that simply peppering a person’s mouth with some Lactobacillus would get people to drop pounds. But that could be where things are headed.

Bacteria also interact with one another. It’s an ecosystem, after all. Decoding these relationships could be the beginning of a new way to treat oral issues, says Ted Jin. He’s the founder of Qii, which makes a canned tea drink designed to encourage balanced mouth bacteria. The beverage is more anti-plaque than anti-cancer, but it’s part of a larger effort by Jin and his team of researchers to understand the intricacies of the mouth biome in order to make better oral-care products down the road.

What experts are learning about the state of our maws isn’t entirely rosy. For one, there’s a hypothesis that the mouths of people in the U.S. aren’t as diverse as they should be. Crappy, overly processed diets with too much sugar and not enough fresh produce are not great for a healthy oral ecosystem. Nor is our fascination with all things antibacterial, which is why experts are beginning to discourage patients from using harsh mouthwashes that kill good and bad bacteria indiscriminately. (The Food and Drug Administration banned certain ingredients in antibacterial hand soap in 2016, in part because they were killing off good bacterial strains and promoting “superbugs.”)

These differences may also help explain why there are areas of the world with less-advanced oral hygiene practices, but where people generally have teeth and gums that are just fine. And in addition to geography and diet, there’s certainly a genetic component to all of this, so if your kid’s got a mouthful of cavities, you’re at least partially to blame.

Another upshot to all of this will come in the form of precision medicine. In the future, you may be able to send off some spit and receive back a mouthwash tailored specifically for your oral microbiome, Jin says. If you have too much of a certain bacteria strain, you could swish with a formula that contains another, which would act like a microscopic smart bomb to get conditions like halitosis (bad breath) or gum disease under control.

You don’t have to wait for the mouthwash of the future to do right by your mouth. For starters, eat a Mediterranean diet, says Jason Tetro, a visiting scientist at the University of Guelph in Ontario and author of The Germ Code. “Staples of the diet, such as fish and vegetables, have omega fatty acids and phytochemicals,” Tetro says. “And in some cases, things like pomegranates have antimicrobials, which seek out and kill bad bacteria and help maintain a less acidic environment.”

His secret weapon against oral inflammation? The sesame paste tahini. It helps promote an alkaline environment in the mouth, Tetro says. So if your maw feels a little sore from fast food or booze, swish with a spoonful of tahini for some low-tech relief.

And low-tech is kind of the point. While researchers like Han are teasing out microscopic secrets, one petri dish at a time, what we’re learning seems to substantiate what we already know. Brushing and flossing is still a great way to keep your oral microbiome healthy. And no more excuses: time to schedule that dentist appointment.

The UK has announced that, after a great deal of pressure, it will be making the HPV vaccine available to teenage boys, potentially protecting them from a number of cancers.

The vaccine is routinely offered to teenage girls in schools. It has shown an impressive safety record while at the same time driving down cervical, oral and throat cancer rates by protecting young women from sexually transmitted HPV.

Campaigners have long said that teenage boys should also be provided the vaccine, because evidence has shown the HPV vaccine can reduce rates of oral, throat, penile and anal cancers. Unfortunately, Public Health England has taken some convincing on this issue, with a cash-strapped National Health Service having to make sure that every investment more than pays its way.

Now, the government says it believes the cost is far outweighed by the public health benefit.

Dr. Mary Ramsay, Head of Immunisations at Public Health England, is quoted as saying, “This extended programme offers us the opportunity to make HPV related diseases a thing of the past and build on the success of the girls’ programme, which has already reduced the prevalence of HPV 16 and 18, the main cancer-causing types, by over 80 percent.”

This change of course comes after the Joint Committee on Vaccination and Immunisation said earlier this month that, after careful review, it believed the HPV vaccination program should be extended to boys, as it found “gender-neutral vaccination is highly likely to be cost effective”.

HPV VACCINE’S SAFETY RECORD IS OVERWHELMING
While there have been some scare stories in the media relating to supposed side-effects from HPV vaccine, it’s important to note that the actual safety record for HPV vaccination is overwhelmingly good.

In fact, a meta-analysis of studies involving over 70,000 women demonstrated that of the 14 deaths per 10,000 that occurred around the time of vaccination, not a single one could be directly linked to the vaccine.

Like every live vaccine, there is the potential for some side effects. HPV vaccine’s side-effects are, for the most part, mild. If a person does have an adverse reaction, it is likely to manifest in localized swelling, a rash, or feelings of fatigue or nausea — all of which will subside on their own within a day or two.

Again, like any medication, there is the potential for more serious side-effects. However, for the HPV vaccine the chances of this happening are incredibly low. The NHS puts it at less than one out of every million cases for reactions like anaphylaxis.

Ah, but aren’t there studies linking HPV to various conditions like fibromyalgia? There have been such small-scale studies. None have found a convincing link, and their size and quality pale in comparison to the data we have to support that, for most women, the vaccine is safe and effective.

It may well be that for a tiny minority of people, the vaccine could present a risk, but that possibility is neither confirmed nor does it outweigh the manifest benefit. The HPV vaccine is thought to save thousands of lives per year globally by preventing cervical cancer deaths.

In short, the weight of not just national but global evidence points to the HPV vaccine saving lives and doing so safely.

WHY THIS MOVE WILL PROTECT GIRLS AS WELL AS BOYS
The fact that the vaccine will protect boys from cancer is, for many, motivation enough to say that the vaccine should be provided to teenage boys.

However, in addition to that, protecting boys from HPV has a knock-on effect for girls. That’s because it cuts down the circulating HPV strains that cause cancer for young women. This means that those young woman who cannot have the vaccine due to their medical history or current conditions will benefit from herd immunity.

It’s estimated that HPV16 and HPV18 circulation has already gone down by 80 percent in the UK as a result of the vaccination program.

In this way, not only are we seeking to eradicate the incredibly common HPV strains, we are also helping to cut our children’s cancer risk. The UK is among the first group of nations to offer the HPV vaccine to both girls and boys, and it is hoped that other nations will follow.

Not just cigarette smokers, those smoking e-cigarettes as well as consuming smokeless tobacco like chewing tobacco and more are at greater risk of developing oral cancer, shows a recent study conducted by University of California.

In case you think only cigarette smokers are at a higher risk of getting oral cancer, you are widely mistaken. A recent study has found that a wide majority of non-cigarette tobacco users as well those using electronic cigarettes are exposed to considerable level of carcinogen, as much as a cigarette user is exposed to. Not just that, shockingly smokeless tobacco users were found at a greater exposure to tobacco-specific nitrosamines (TSNA). The study has been conducted by the scholars from University of California, San Francisco.

What is Oral cancer?
Belonging to the head and neck cancer group, oral cancer is a type of cancer that grows in mouth or throat tissues and mostly hit the squamous cells of your mouth, tongue and lips. Oral cancer can of several types – lip cancer, tongue cancer, cancer in the inner lining of your cheek, gums, floor of the mouth and hard and soft palate. It is important to go to a dentist for a biannual check-up for early detection of oral cancer, experts say. Due to lack of awareness and adequate check-ups, oral cancer gets detected only after they spread to the lymph nodes of the neck.

The other risk factors
Apart from tobacco consumption, both smoke and smokeless and excessive alcohol consumption, there are several other risk factors that can put you to greater risk of developing oral cancer. Human papillomavirus (HPV) infection, chronic facial exposure to sun, a former diagnosis of oral cancer, a family history of oral or any other types of cancer, a depleted body immune system, inadequate nutrition, genetic syndromes are other risk factors for oral cancer. Shockingly, being male is another potent risk factor as studies have found males to be at a higher risk of developing oral cancer, twice as likely compared to women.

A review that covered nearly 20 million people has confirmed that people with diabetes face a higher risk of cancer, and that risk is higher among women than men.

Findings published in Diabetologia, the journal of the European Association for the Study of Diabetes, showed that women with type 1 of type 2 diabetes were particularly at risk for cancers of the stomach, mouth, and kidney.

The authors reviewed articles appearing in PubMed through December 2016, and ended up including data from 106 articles in the study. This allowed the review to evaluate gender-specific effects of diabetes on overall cancer risk as well as 50 site-specific cancers.

Results covered data from 47 countries. Authors called it “the most comprehensive analysis to date on the sex-specific effects of diabetes on cancer risk.”

Overall, the review showed diabetes is a risk factor for most cancers, and that women with diabetes were 6% more likely than men with the disease to develop some form of cancer. Among people with diabetes, researchers also found:

Women were 27% more likely to develop cancer than those without diabetes. Men faced a 19% higher risk of cancer.

Of note, women faced an 11% higher risk of kidney cancer, a 13% higher risk of oral cancer, a 14% higher risk of stomach cancer, and a 15% higher risk of leukemia than men.

Liver cancer was an exception: the risk for women with diabetes was 12% lower than that of men.

Sanne Peters, PhD, of The George Institute for Global Health at the University of Oxford and a study coauthor, said that women may be more likely to develop cancer than men with diabetes because they are in prediabetes longer than men; typically, women develop impaired glucose tolerance that goes unaddressed for up to 2 years longer than men.

“Historically, we know that women are often untreated when they first present with symptoms of diabetes, are less likely to receive intensive care and are not taking the same levels of medications as men,” Peters said in a statement. “All of these could go some way into explaining why women are at greater risk of developing cancer. But without research we can be certain.”

Peters and lead author Toshiaki Ohkuma, a research fellow at the Global Institute, said the results show why gender-specific research is important. While the link between diabetes and cancer has been known for some time, Ohkuma said, “We have also demonstrated for the first time that women are more likely to develop any form of cancer, and have a significantly higher chance of developing kidney, oral, and stomach cancers, and leukemia.”

Elevated blood glucose seen in diabetes is believed to damage DNA, causing cancer. However, the authors wrote, “Further studies are needed to clarify the mechanisms underlying the sex differences in the diabetes–cancer association.”

More than 30 million people in the United States have diabetes, with 95% of the cases being type 2 diabetes. Worldwide, more than 415 million people have the disease.

Reference
Ohkuma T, Peters SAE, Woodward M. Sex differences in the association between diabetes and cancer: a systematic review and meta-analysis of 121 cohorts including 20 million individuals and one million events. Diabetologia, 2018. doi: 10.1007/s00125-018-4664-5.

Singing hymns in church has always brought Cynthia Zamora joy. Today, her once sharp intonation has given way to a raspy voice. But Zamora is thankful that she has a voice at all after spending three months without the ability to utter even one syllable.

“I miss going to church and singing with people,” said Zamora. “Although, if I am in the back I’m still singing. I’m just hoping they don’t hear what sounds like a 13-year-old pubescent boy back there, because that’s how I sound. I know God thinks it’s beautiful, so I don’t worry about it. I just go on with life.”

In 2017, Zamora bit her tongue while sleeping, splitting her tongue nearly in half. She was referred to a specialist when her wound would not heal. They found a 5.4-centimeter tumor that enveloped more than half of her tongue. To save her life, her surgeon, Joseph Califano, MD, delivered grim news: Zamora would have to undergo a glossectomy — the surgical removal of all or part of the tongue.

“By the time I saw her she was really having a hard time speaking and swallowing,” said Califano, director of the Head and Neck Cancer Center at UC San Diego Health. “With Cynthia that was a difficult discussion because it was unclear how much tongue we would save and how good the function would be with the remaining tongue that would be preserved.”

A multidisciplinary team of experts that included medical oncology, surgical oncology, reconstructive surgery, radiation oncology, speech therapy, nutrition, psychiatry and a host of others came together to design a comprehensive plan to eradicate an aggressive, stage IV squamous cell carcinoma and deliver the best quality of life for a woman who was about to undergo a catastrophic surgery.

“The tongue is critical. It’s one of the strongest muscles we have in our body. In speech, our tongue is moving so rapidly within the confines of our mouth in order to generate and make certain sounds in conversation that we find it’s hard to grasp how complex that action is,” said Liza Blumenfeld, speech-language pathologist at Moores Cancer Center at UC San Diego Health. “Without a tongue you’re having to compensate for all of that movement with other structures, your lips, your cheeks and your jaw.”

During a 12-hour surgery, Califano would remove a large portion of Zamora’s tongue and place a breathing tube and feeding tube before a reconstructive microsurgeon would step in to replace the portion of tongue that was removed.

“The primary goal of surgery is to remove the cancer as best we can while sparing as much normal tissue as possible,” said Califano. “It was a challenging surgery in that we had to cut just right to save enough tongue so that she would have some function and we could still get well around the tumor. We were able to save less than half her oral tongue. That wasn’t a lot.”

Ahmed Suliman, MD, a plastic surgeon who specializes in reconstruction after cancer treatment, was tasked with reconstructing her tongue.

“When you remove the majority of the tongue you can’t really function,” said Suliman. “You can’t swallow and articulation is limited. We had to rebuild a tongue to provide bulk so that Cynthia could move food in her mouth in order to swallow and to speak.”

He used a method called anterolateral thigh perforator flap (ALT). Suliman cut a 6 by 8 centimeter tissue of skin and fat from Zamora’s leg to shape and create a new tongue. The replacement tongue does not move, but because Califano was able to spare the base of her original tongue, Suliman was able to reconstruct using the remaining tongue base to preserve some movement for Zamora. Suliman sutured the new tongue, attaching one artery and a vein from the neck using a microscope.

The reconstructive surgery and dissection of cancerous tissue in her tongue and lymph nodes left Zamora temporarily unable to walk, talk or eat. One of the advantages of performing an ALT is that minimal thigh muscle, or none at all, is cut when extracting tissue for the new tongue. This allows for a faster recovery because Zamora did not lose leg muscle function, so with physical therapy Zamora was on her feet fairly quickly.

Skin and fat tissue are more resilient to radiation therapy than muscle, said Suliman, making this tissue more ideal for someone like Zamora, who received treatment following surgery.

“The success of management of these advanced cancers rely on the coordinated efforts of a multi-disciplinary oncologic team,” said Suliman. “This leads to better planned surgery, good preoperative and post-operative care, and follow up. The success of complex cases is higher and outcomes are better, as demonstrated by Cynthia.”

While Zamora was undergoing physical therapy and speech therapy, she was also undergoing chemotherapy, radiation and was receiving an experimental immunotherapy called Pembrolizumab (Keytruda), an antibody that inhibits the abnormal interaction between the molecule PD-1 on immune cells and the molecule PD-L1 on cancer cells, allowing the immune cells to recognize and attack tumors. Pembrolizumab is FDA-approved for some cancers, such as melanoma but is still under a clinical trial for squamous cell carcinoma of the head and neck .

While Zamora continued aggressive treatment and attended physical therapy, she also met with Blumenfeld.

“Teaching somebody to regain their speaking and swallowing abilities during head and neck cancer treatment is really difficult,” said Blumenfeld. “Being able to understand what their abilities were like before, and being able to understand what their new normal looks like, helps us play on their strengths and their ability to compensate with other structures.”

Blumenfeld and Zamora worked together targeting the sounds that she had problems expressing. Zamora had to slow her speech and exaggerate each sound, compensating with her vocal chords for sounds she can no longer make with her tongue.

It is a tedious process but in three months Zamora was speaking well again.

“Previously, I was well pronounced with an expansive vocabulary. I had to be patient with myself and use more expressions in my eyes, hands and face. Sometimes I have to pick words I wouldn’t normally use because I can’t use my original vocabulary. Quality is better than quantity,” said Zamora.

“You have to want to be able to communicate in order to talk, and I wanted that more than anything, because I am a person who loves to communicate. I haven’t got singing down yet, but hopefully that will come.”

Zamora’s vocal chords are healthy and with time, patience and modifying her technique, Blumenfeld thinks that Zamora will be singing “proudly, loudly sometime soon.”

“There are people that come into your life as patients and your mind is blown by their strength of character, their humor, their wisdom, and their willingness to fight. Cynthia really embodies all of those things,” said Blumenfeld. “From the first day she was insistent that she was going to come out of this as a stronger, better person. She has really shown me, even in my own personal life, to never give up and to set your mind on a set target, and you simply do not deviate from that.”

In addition to regaining her speech, Zamora would need to relearn to eat. This was her last hurdle to recovery. It was only in early 2018 that she began to eat without a feeding tube.

“I would encourage everybody to think for a moment of what life would be like. Grab your tongue with your teeth and try to talk without a tongue. Try to think about, when you take a bite of a sandwich, everything that’s going on in your mouth,” said Blumenfeld. “In order for us to be able to chew, we have to be able to manipulate food, move it from one side of our mouth to the other side of the mouth. We have to be able to organize all that food on top of our tongue and propel that food backwards in order to swallow it. Without a tongue that becomes almost an impossible task.”

Thankfully, Zamora mastered the ability to eat again and laughs when recalling eating half a lava cake in front of her shocked family during a restaurant outing. She eats crispy fried chicken and just about anything she wants.

“With a little patience and care, and one step, baby steps, along the way, you can do anything,” said Zamora. “Look at me. I had no tongue, and I’m talking. I’m eating. I’m drinking. I’m doing great. There is life after this surgery. Don’t give up. Keep going. Be strong. Be stubborn. You can do it, you can.”

When it comes to the health risks associated with smoking, most people know about lung cancer and heart disease. But less than a third of Australians realise it can also cause conditions such as acute leukaemia and rheumatoid arthritis, according to a new study, raising the question around whether current graphic cigarette warning labels need to be refreshed.

The study, published in the Medical Journal of Australia, asked 1,800 Australians about whether they thought smoking increased the risk of 23 conditions shown to be associated with tobacco use, such as lung cancer, stroke and diabetes.

While more than eight in 10 participants knew lung, throat and mouth cancers, heart disease and emphysema were linked to smoking, much fewer were aware it was associated with erectile dysfunction, female infertility, diabetes and liver cancer.

The results showed the current warning labels were doing their job, and that it might be time to expand them, said Michelle Scollo from Cancer Council Victoria, which ran the study.

“It was predictable and pleasing that smokers knew about the health effects that have been highlighted in the current sets of warnings and media campaigns,” Dr Scollo said.

“[But] fewer than half realised it could reduce your fertility, and that could have a really major impact on the course of people’s lives … There’s a lot that people need to appreciate.

Part of the reason the link between smoking and some of the conditions surveyed aren’t well known is because research into the health effects of tobacco use has advanced since the time the current warnings were developed, Dr Scollo said.

The current set of graphic warning labels have been in place since 2012.

“In 2014, the US Surgeon-General released a 50-year report — they released a whole updated statement of the diseases caused by smoking. Many more conditions were added to the list in 2014,” she said.

“These health warnings came into effect in 2011-12 and a lot more things have been established. Liver cancer, colon cancer … diabetes, erectile dysfunction.”

Dr Scollo hoped the research would lead to an expanded campaign including new graphic warning labels, showing more of smoking’s health risks.

“People need continuous reminders of these sort of things if they’re going to remember them but I don’t see why we need to be limited to just 14 warnings,” she said.

“I think we need as many warnings as we need to adequately warn people about the risks they face.”

There is value in looking at people’s awareness of smoking’s risks, according to Australian National University anthropologist Simone Dennis, who researched the effects of the original graphic warning label campaign.

But she cautioned against automatically reaching for more graphic warning labels as the solution.

Health warnings about smoking were usually framed around a “particular middle-class version of health” and the assumption that more knowledge will change people’s behaviour, said Professor Dennis, who was not involved in the most recent study.

She said the original graphic warnings were effective in reducing smoking, especially among white, middle-class people, but doubted refreshing the campaign would see a similar reduction.

“I don’t know that the constant articulation of danger is doing anything for the people who are smoking,” she said.

The danger, Professor Dennis said, was that people whose behaviour wasn’t changed by the warning labels tended to be from marginalised groups, and pushing the same line risked marginalising them further.

When you learn you have cancer, you want to know what to expect: How will doctors treat your illness? How effective is treatment likely to be?

Much depends on the way doctors first classify, or “stage,” your cancer, using the official staging manual from the American Joint Committee on Cancer. Staging guidelines continue to evolve as knowledge about individual tumor growth and innovative technologies come into play.

An ever-evolving system
“Historically, we staged cancers according to tumor size, lymph node involvement and the presence of metastases,” says oncologist Dale Shepard, MD, PhD.

“The latest staging manual incorporates new findings on the importance of changes in molecular DNA and tumor genomic profiling. This will affect many patients going forward.”

Among those most impacted by changes in staging are people newly diagnosed with breast cancer; head and neck cancer caused by human papillomavirus (HPV); or sarcoma.

How staging works
“Staging allows us to stratify patients into groups based on anatomic and other criteria. It gives us a framework for understanding the extent of disease,” Dr. Shepard explains.

Cancers are staged clinically and pathologically:

The clinical stage is determined during the initial workup for cancer.

The pathologic stage is determined by studying a surgically removed tumor sample under the microscope.

Adds Tumor Registry ManagerKate Tullio, MPH, MS, “Staging helps physicians and other researchers to compare patients with the same types of cancer to each other in a consistent way — so that we might learn more about these cancers and how to effectively treat them.”

Staging allows doctors to determine the best course of treatment for different types of cancer and helps families to understand the prognosis, or likely outcome, of that treatment.

It also allows doctors to offer patients a chance to participate in clinical trials of new therapies targeting their form of cancer.

The impact of DNA changes on breast cancer
In the past, most breast cancer patients with lymph node involvement were automatically classified as stage II or higher, and were often given chemotherapy.

“Previously, physicians considered only tumor size, lymph node involvement and spread of the cancer to distant areas of the body when staging breast cancer,” says Ms. Tullio.

Today, staging has improved with the addition of advanced multi-gene panel testing and specific information on the biology of the tumor.

“This incorporates what we have found clinically: that some patients previously identified with stage II breast cancer did better than others,” says Dr. Shepard. “In essence, patients with HER2-positive disease were more like patients with stage I disease.”

HPV’s effect on head and neck cancers
The classification of head and neck tumors has changed because of advances in genomic profiling.

“We now have a separate system for classifying head and neck cancer caused by HPV infection because we realize that, clinically, it is a different disease,” says Dr. Shepard.

Ms. Tullio notes that patients with head and neck cancers caused by HPV have a better prognosis — living longer, on average, than head and neck cancer patients without HPV.

“Patients with HPV-positive mouth or throat cancers usually respond well to treatment and may need less aggressive therapy than those who are HPV-negative,” she says.

Also new, adds Dr. Shepard, are separate classification systems for soft-tissue cancers called sarcomas. Doctors have found that, based on the primary tumor’s location, sarcomas will behave and respond to treatment differently.

How will these changes affect you?
The impact of these staging changes will be far greater for patients with cancers diagnosed on or after Jan. 1, 2018.

“If your cancer is new, then changes in classification may affect early decisions about your initial care and likely prognosis,” says Dr. Shepard.

If you received a cancer diagnosis before that date, the stage of your tumor will not change, Ms. Tullio notes. However, new data in the manual may allow your doctors to better assess and treat you.

Adds Dr. Shepard, “Talk to your doctor if you have any questions about the new staging systems. It’s important to be sure all the right tests are ordered to accurately assess your cancer.”

Dry mouth is a common problem and has been reported by up to 47 percent of people at some point in their lives. Dry mouth tends to have a higher prevalence in older individuals and is more likely to occur in women.

Many factors can cause dry mouth, including Sjögren syndrome. However, many people, particularly those with Sjögren syndrome, may underestimate their levels of oral dryness and may never seek professional help.

Sipping water can temporarily help patients relieve the sensation, but it has limited effectiveness.

Researchers in this study set out to determine if symptom relief can be obtained from a newly developed moisturizing mouthwash. While the formulation used to make this mouthwash is similar to those previously available, a different preservative system that incorporates cetylpyridinium chloride (CPC) instead of parabens was used.

Researchers recruited patients with self-reported dry mouth, some of whom had Sjögren syndrome. To determine the mouthwash’s effectiveness, researchers used questionnaires both before and after use.

The product performance and attributes questionnaire (PPAQ) previously has been validated as an appropriate tool to determine the efficacy of dry-mouth products. Participants were randomized to receive either the experimental mouthwash or water only. For eight days, the mouthwash group used 1-2 doses per day at home. Both groups were allowed to sip water if needed.

Supervised treatment took place on days 1, 3, and 8. During treatment, before and after administration, participants completed the PPAQ, parts 1 through 4.

The primary endpoint of the study was relief of dry mouth symptoms, as determined by question 1 of the PPAQ3 — “Relieving the discomfort of dry mouth” — at 120 minutes after use of the experimental mouthwash or water, after eight days of treatment.

Researchers found that individuals in the mouthwash group had significantly more relief of dry mouth symptoms versus participants in the water-only group. Patients without Sjögren syndrome seemed to favor the mouthwash, but this was not the case in patients who had the syndrome. Regarding safety, eight non-serious, treatment-related adverse events were reported by the mouthwash group.

“The findings of a subjective questionnaire showed that an experimental moisturizing mouthwash provided greater relief than water only from dry mouth symptoms over 8 days,” investigators concluded.

“The study shows that efficacy and oral tolerance are retained with the use of CPC as a preservative and adds weight to the use of PPAQ as a measure to distinguish dry mouth remedies,” they added.